Provider Demographics
NPI:1376258038
Name:MARIAM S AMIRI D P M PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARIAM S AMIRI D P M PROFESSIONAL CORPORATION
Other - Org Name:LOMA LINDA AMBULATORY SURGICAL CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-522-7413
Mailing Address - Street 1:11332 MOUNTAIN VIEW AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3854
Mailing Address - Country:US
Mailing Address - Phone:951-314-3088
Mailing Address - Fax:951-379-5310
Practice Address - Street 1:11332 MOUNTAIN VIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3854
Practice Address - Country:US
Practice Address - Phone:951-314-3088
Practice Address - Fax:951-379-5310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical